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General NPI Number Information
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NPI Number | 1952595878
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Entity Type | Organization
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Legal Business Name | CLARKSON OPTOMETRY ILLINOIS PC
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Dates
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Enumeration Date | 09/04/2007
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Last Update Date | 01/31/2018
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Provider Practice Location Address
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Address Line | 210 S MAIN
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City | RED BUD
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State | IL
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Zip | 62278
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Country | US
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Telephone | 618-635-3535
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Fax | 618-282-2830
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Provider Business Mailing Address
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Address Line | 15933 CLAYTON RD STE 201
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City | BALLWIN
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State | MO
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Zip | 63011-2172
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Country | US
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Telephone | 636-200-4393
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Fax | 636-527-0766
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Authorized Official
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Title or Position | CMO
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Name | DR. JAMES J WACHTER
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Credential | OD
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Telephone | 636-200-4393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State | IL
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